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Internship Application

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WESTMORELAND COUNTY OFFICE OF THE CORONER&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp Internship Program Application

Date of Application*

Date of Application

Semester Requested*

Full Name*

Email*

Age*

Date of Birth*

Date of Birth

Sex*

Male

Female

Social Security #*

Home Address*

City*

State*

ZIP*

Home Phone

Cell Phone*

Drivers License# and State*

Copy of Drivers License*

Upload scanned drivers license here

Medical Insurance*

Copy of Medical Insurance*

Upload scanned medical insurance here

Any medical or physical conditions that would limit your ability to perform duties of an intern?*

No

Yes

Explain Limitations

School or University*

Advisor Name*

Advisor Phone*

Address*

City*

State*

Zip*

Current Year of Study*

Anticipated Graduation*

Anticipated Graduation

Major*

#Credits Received for Internship*

Is this internship a requirement for your major?*

No

Yes

Minimum Hours*

(required by school)

Any additional requirements required by school or university

Attach Resume*

Attach Essay*

Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my internship application.